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The lack of a medically grounded approach to personality disorder and its management has led to its comparative neglect as a topic by many clinicians in the UK. In this article we present evidence that personality disorders are, like other mental disorders, the social manifestations of a pathological process. This process presents with characteristic clinical features that are developmental in nature. These cause disturbances in arousal, affect and reality testing that have an impact on interpersonal social functioning. Personality disorder may therefore be conceived of primarily as a socioemotional disability, not dissimilar to Axis I conditions.
Routine outcome measures are essential to chart individual patient progress and evaluate models of service provision. The Health of the Nation Outcome Scales (HoNOS) were commissioned by the Royal College of Psychiatrists as a simple, brief measure for this purpose. It is one of the most widely used outcome measures in mental health services globally and has been translated into at least seven languages. Its use has broadened beyond its original purpose and in several countries collection of HoNOS data is mandatory. We review 585 potential articles to chart the development and evolution of HoNOS, as well as its psychometric properties, qualitative attributes and uses in clinical practice and research. The potential barriers to implementation of HoNOS on a wide scale are considered and its future role in evaluating effectiveness and benchmarking of services are discussed.
Routine use of Health of the Nation Outcome Scales (HoNOS) has not produced the anticipated benefits for people using mental health services. Four HoNOS-specific reasons for this are: low relevance to clinical decision-making; not reflecting service user priorities; being staff-rated; and having a focus on deficits. More generally, the imposition of a centrally chosen measure on the mental health system leads to a clash of cultures, since frontline workers do not need a standardised measure to treat individuals. A better approach might be to use research from the emerging academic discipline of implementation science to inform the routine use of a standardised measure that is chosen by the people who will use it and hence is more concordant with existing clinical processes. This is illustrated using a case study of successful implementation of the Camberwell Assessment of Need (CAN) in community mental health services across Ontario, Canada.
There has been little research into the interaction between fraud offences and mental health. Fraud is perpetrated on a massive scale and a number of offenders will have psychiatric pathology either as a primary driver of the offence or as an associated phenomenon that will require psychiatric care and treatment. This article reviews the broad range of psychiatric conditions that have been associated with fraud offending, comments on management and discusses methods of psychiatric assessment in fraud offences.
The complex nature and consequences of fraud are illustrated by the case of ‘Dr’ Barian Baluchi, who held himself out to be a consultant neuropsychiatrist before being convicted of deception, actual bodily harm and procuring registration by making false declarations. Under the proposed UK Criminal Evidence (Experts) Bill, psychiatric experts in fraud cases are likely to find the admissibility of their evidence tested against statutory criteria. Where they rely on test results, they will need to know the validity of the methods and show that they have taken proper account of the degree of precision or margin of uncertainty affecting the accuracy or reliability of their results. Proposals to reform the law on unfitness also have implications for psychiatric assessment in fraud cases. It will now be even more important for psychiatric opinion evidence to be demonstrably sound and of such evident strength that there is no issue as to its admissibility and the judge can presume evidentiary reliability.
Increasing attention is being paid to the concept of attention-deficit hyperactivity disorder (ADHD) in adults, in concord with evidence that suggests a proportion of children with ADHD continue to manifest symptoms into adulthood. Attention-deficit hyperactivity disorder has some symptoms in common with hypomania, and can co-occur with bipolar disorder. The diagnosis and management of ADHD in adults with bipolar disorder can be complicated, owing to challenges resulting from symptom overlap, questions of diagnostic validity and a paucity of empirical evidence to guide treatment. This article addresses comorbid ADHD and bipolar disorder, and provides practical suggestions for diagnosis and management.
Issues relating to capacity are increasingly topical and relevant, particularly following the implementation of the Mental Capacity Act 2005. Powers of attorney are one such issue that requires the assessment of capacity for their execution. This article focuses on lasting powers of attorney (LPAs), which were introduced under the Mental Capacity Act in 2007. We describe how LPAs evolved and how they have been used since the inception of the Act. We review salient case law. In doing so, we elucidate pertinent issues for clinicians, particularly in the case of health and welfare LPAs: for the first time in England and Wales, the law allows donors to nominate an attorney to make decisions about their personal health and welfare once they become incapacitated.
Scottish legislation on incapacity differs significantly from English and Welsh legislation. Clinicians must be aware of the authority of attorneys, especially in relation to welfare and medical treatment. The number of welfare attorneys is growing and they may not be aware of how best to use their powers.
There is clear evidence of increased medical comorbidity and related mortality in people with severe mental illness, despite numerous guidelines for managing medical conditions in this population. This article assesses inequalities in medical treatment and preventive healthcare received by psychiatric patients compared with the general population. It considers whether the medical care provided is adequate and whether published guidelines improve it. Mental health specialists, general practitioners and hospital specialists appear to deliver poorer than average medical care for this vulnerable population. Implementation of physical healthcare guidelines is incomplete and the guidelines must be matched with resources to address this deficit.
Fyodor Dostoyevsky is widely regarded as the greatest 19th-century Russian writer and a giant in world literature. He is familiar to literary-inclined psychiatrists for his rich and accurate portrayal of mental illness in several of his works. But his own chronic addiction to gambling and its consequent perils are less well-known. This article discusses The Gambler, one of Dostoyevsky's early (1866) semi-autobiographical novellas, inspired by his own addiction to roulette, focusing on its depiction of gambling. To better understand Dostoyevsky the gambler, the article also presents brief excerpts from letters that he wrote to his wife in 1867, when his gambling addiction appears to have been at its worst. Finally, the relevance of the central theme of this work, gambling addiction, to the present-day psychiatrist is discussed.
Cognitive dysfunction is one of the major contributors to the burden of epilepsy. It can significantly disrupt intellectual development in children and functional status and quality of life in adults. Epilepsy affects cognition through a number of mechanisms in complex interrelationship. Cognitive deficits in epilepsy may be treated indirectly through aggressive seizure control using anti-epileptic drugs or surgery, and by treating comorbid conditions such as depression. The beneficial effects of reducing seizures may offset the adverse cognitive side-effects of these therapies. Direct treatment of cognitive impairment in epilepsy mainly involves memory rehabilitation. Other direct treatments are mostly experimental and their evidence base is currently poor.